Transcript in situ - EmorySurgery

Vascular and Intestinal
Anastomotic Workshop
PGY 1
Name the Instruments
PGY 1
Name the Instruments
PGY 1
Name the Instruments
PGY 1
Commonly used Sutures
Braided?
Absorbable?
Timeline
# of throws
Silk
Braided
no
n/a
3-4
Vicryl
Braided
yes
55-70 days
4-5
Prolene
Mono
no
n/a
6-8
Chromic
Mono
yes
90 days
4-5
PDS
Mono
yes
180-210 days
6-8
Nylon
Mono
no
n/a
~5
Gore
Mono
no
n/a
~8
Monocryl
Mono
yes
90-120 days
5
PGY 2
Lembert Sutures
• Definition?
• Reason?
PGY 2
Connell Sutures
• Describe Connell suturing technique
Staplers
PGY 2
Name the Stapler
PGY 2
Name the Stapler…
PGY 2
Name the Stapler
PGY 2
Side to side anastomosis
• How do you set up a side to side anastomosis?
CRITICAL CONCEPTS
• Non-tension
• GIA stapler
• Align anti-mesenteric
sides of bowel together
• Staggered staple lines
PGY 2
End-to-end Anastomosis
• How do you
set up a
stapled endto-end
anastomosis?
PGY 2
Functional End-to-end anastomosis
• Describe another way to perform a stapled
end to end anastoamosis
PGY 3
Stapler Loads
• What is the
•
difference between
the different stapler
loads?
What color load do
you use for vascular
tissue? Stomach?
Small bowel?
Colon? Rectum?
PGY 3
Hand Sewn Anastomosis
• Describe the different
types of suture
techniques used in
hand sewn bowel
anastomosis
PGY 3
Hand Sewn Anastomosis
• Describe the
steps for a 2
layer
anastomosis
PGY 3
Hand Sewn Anastomosis
• Describe how to sew a single layer
anastamosis
PGY 2
Arm Vascular Anatomy
• Describe
the arterial
and venous
blood flow
to the arm
PGY 2
Types of Surgical Dialysis Access
• What is the
difference
between an
AV Fistulae
and an AV
Graft
Sites for AV fistulae
Radiocephalic AV Fistula
Brachiocephalic AV graft
Basilic Vein Transposition
DRIL procedure
• DRIL = Distal
Revascularization
Interval Ligation
• RUDI = Revision
Using Distal
Inflow
PGY 3
Vascular Anastomosis
• Identify autogenous materials for vascular
anastomosis:
– Saphenous vein, iliac vein
• Identify exogenous materials for vascular anastomosis:
– bovine pericardium, ePTFE, gore-tex, cadaveric
• What is the dosing/timing for heparinization during a
vascular anastomosis?
– 75-100 units/kg, given 5 minutes prior to vascular
occlusion
• How do you measure heparinization to confirm
appropriate levels have been achieved?
– Activated clotting time (ACT) of greater than 250
PGY 3
Zones of Retroperitoneum
• Describe the Zones of the retroperitoneum
and the major vasculature that could be
injured in each zone
• Zone 1: Midline retroperitoneum
– Supramesocolic region (suprarenal aorta,
celiac, SMA/SMV, proximal renal artery)
– Inframesocolic region (infrarenal aorta,
infrarenal IVC)
• Zone 2: Upper lateral retroperitoneum
(renal artery/vein)
• Zone 3: Pelvic retroperitoneum (iliac
artery/vein)
PGY 3
Zone I Great Vessel Injury
• Describe the approach
for supramesocolic
Zone I injuries:
– Left medial visceral
mobilization
– May also need to
transect the left crus
(at 2o’clock position) to
allow for control of the
descending thoracic
aorta
PGY 3
Zone I Great Vessel Injury
• Describe the approach for
inframesocolic Zone I injuries:
– Lift up on transverse mesocolon,
eviscerate small bowel to right,
open mid-line retroperitoneum
and cross clamp the aorta
inferior to the left renal vein
– For IVC injuries, perform a right
medial visceral mobilization
(right colon and duodenum),
leaving the kidney in situ
PGY 3
Zone I Great Vessel Injury
• Describe the approach to an inframesocolic
Zone I injury to the IVC at the common iliac
vein confluence:
– After right medial visceral mobilization, it may be
necessary to divide and ligate the right internal
iliac artery or to temporarily divide the right
common iliac artery
PGY 3
Zone I Great Vessel Injury
• Describe the approach to an inframesocolic
Zone I injury to the IVC at the level of the
renal veins:
– After right medial visceral mobilization, you
should clamp/compress the IVC proximally and
distally and loop/clamp both the left and right
renal veins. It may be necessary to perform a
medial mobilization of the right kidney (watch out
for 1st lumbar vein!)